Concussion

A concussion occurs when a significant force to your head or body is sustained, leading to a traumatic force to your brain. This sudden and abrupt motion of the brain within your skull can create chemical and mechanical changes within your brain; it is not a bruise, it is a mild trauma (1). Concussions are usually non-life-threatening, but the symptoms are often significant, uncomfortable, and potentially life changing. It is incredibly important to take the time to treat your concussion properly when one occurs, and to protect and prevent your brain against getting one, or multiple, concussions. In the news recently, many people have been discussing Chronic Traumatic Encephalopathy, or CTE. CTE is a condition caused by chronic trauma to the brain, leading to a buildup of tau protein in the brain, causing chemical changes in the brain with long term damage (2). Education about signs and symptoms of concussion to coaches, families, athletes, and all other people is so important because the more eyes on people who are at risk the more we can prevent long term damage to everyone’s brain. This is does not occur from one concussion, but repetitive injury to the brain. Treating your concussion is a slow process, you should work with a physical therapist or other qualified healthcare provider to address your symptoms and take the steps to quality rehabilitation.

Symptoms & Diagnosis

A person can typically feel when they’ve had a concussion immediately and if you are an observer, you usually know exactly when a concussion occurs even if you aren’t trained to recognize them. This recognition usually looks like “oh, that looked bad” when someone gets hit in the head. There are two kinds of symptoms related to concussion: observed and self reported.

Symptoms of concussion that are observed by others include: (1, 3)

• The patient not being able to recall the event
• Appearing stunned, dazed, or confused
• Tripping, walking/moving clumsily
• Brief or extended loss of consciousness
• Mood, behavior, or personality changes

Symptoms of concussion that are typically patient reported are:

• Headache or pressure in your head
• Nausea or vomiting
• Imbalance, dizziness, or blurry vision
• Feelings of haziness, grogginess, or sluggishness
• Feeling down, or “not right”
• Changes in sleep, either increased or decreased

Many of these signs and symptoms commonly occur immediately after your injury, but can last for an extended period of time. Testing for a concussion is often a cognitive test, a neurovestibular exam, and potentially scans like a CT or MRI.

The most immediate test for a concussion is a memory test, the ImPACT; for this you need a baseline and a follow up test (3). It tests for IF you have had a concussion, and can be performed if you have taken a baseline measure before beginning your season, this is a common protocol in athletes. Another way to assess symptoms right after injury, and throughout your treatment is a post-concussive checklist, which can be found here (4). Rehabilitating your entire system and all of your symptoms is really important, and dizziness specifically needs to be addressed as well.

Dizziness from a concussion can be a remnant of your injury, and is typically within your vestibular system. This is part of post-concussion syndrome. Post-concussion syndrome is when headaches and dizziness last weeks to months after your initial injury (5). Commonly, post-concussion syndrome patients have vertigo caused by BPPV, episodic dizziness caused by endolymphatic hydrops, concussion induced migraines, or a vestibular hypofunction (6). It is important that if you are having dizziness after a concussion that you seek out proper medical care for treatment.

Treatment

I have frequently heard the following statement from patients, families, and friends: “Oh, I treated my concussion, I just slept for a week and then went back to work”, however contrary to popular belief, this is not how a concussion should be managed. Treatment for a concussion is going to be all about a slow return to your prior level of function, without exacerbating your symptoms. First, yes, you are going to have to rest, but not just laying around your house watching TV. Although physical rest is important, we must also rest our brains. This includes avoiding stimuli like: TV, books, texting, radio, bright lights, and others. Sleep does count as rest, it is a good thing here, but sleeping for a week and then immediately returning to your prior level of function can be dangerous and provoke your symptoms. Slowly returning to your normal activities and rehabilitation can begin after a 14 day period of no symptoms at baseline. Then, you can start to complete physical and vestibular rehabilitation.

Vestibular rehabilitation will be vital as will return to exercise and return to school/work protocols. Vestibular rehabilitation will treat your symptoms such as headache, dizziness, imbalance, and lightheadedness. Physical rehabilitation can be done with a vestibular physical therapist as well, this will help returning to athletic activities, return to work, and return to school. You will be performing brain adaptation, habituation, cardio exercise, and gaze stability. Establishing an exercise program in clinic that you can, and will, perform at home is important to your recovery. The purpose of rehabilitation is to reduce dizziness through repeated exposure to the stimuli that make you dizzy and mildly uncomfortable. These exercises may make your dizziness feel worse for a short period (less than 10 minutes), but continuing to complete these exercises will make you feel better when done properly and consistently.

Rehabilitation is generally performed in 6 steps. This is different for everyone, but for athletes it looks like this:(1)

1. Return to general activity, like work or school.
2. Light aerobic activity, activity that slightly increases your heart rate, for 5-10 minutes like stationary biking or a short walk
3. Moderate activity, activity that increases your heart rate moderately with body or head movement, like moderate weight lifting for less time and intensity than your prior level of function
4. Heavy, non-contact activity. This includes activity in all 3 plans of motion, sprints, and heavy lifting
5. Practice and full contact, which includes full days of practice that include contact from teammates, however no competition
6. Competition and return to function. At this step you may return to your complete prior level of function

It is incredibly important that you work with your healthcare provider to properly grade this plan for you specifically. Throughout these steps, be sure to treat your dizzy symptoms through vestibular rehabilitation while you’re also performing cardio exercise and weight lifting. This can include walking with head turns, VORx1 exercises, and VOR cancellation. Be sure that between each step you have no symptoms for at least 24 hours after your treatment. If symptoms return or increase during treatment, stop and rest; you should return to the previous step when the symptoms stop and you wait until your provider says you may begin again.

Physical Therapy

Treating all of your concussion symptoms is equally important, and a physical therapist is going to be a vital part of your team through this. Vestibular and physical rehabilitation will help your gaze stability, headaches, return to sport, work, and school, and dizziness symptoms. Your PT will help you slowly return to these activities at a graded pace that will be safe and effective while mitigating and treating your symptoms (7). There are many concussion rehab protocols, and your PT will assist you in choosing the right one for you specifically. As a PT, I have seen many patients who believe they have recovered completely, but can’t figure out why they’re still so dizzy. However, treating your dizziness should be a part of your concussion rehab, and it’s why finding a vestibular therapist will be specifically important. A vestibular physical therapist treats dizziness symptoms from any cause, including concussion, and will be able to determine the exact treatment you need to reduce your dizziness. Every concussion is considered serious, and even if you are feeling like you don’t need to you should seek medical assessment to see if you need treatment (8). Concussion treatment is for all people with head injuries, not just athletes.

Sources:

(1) CDC.gov. (2019, February 12). What Is a Concussion? Retrieved August 28, 2020, from https://www.cdc.gov/headsup/basics/concussion_whatis.html

(2) The Concussion Blog. (2019, July 31). What is CTE? Retrieved August 28, 2020, from https://theconcussionblog.com/what-is-a-concussion/what-is-cte/

(3) UPMC Sports Medicine. (2020). Concussion Signs, Diagnosis, and Treatment: UPMC. Retrieved August 28, 2020, from https://www.upmc.com/services/sports-medicine/conditions/concussions

(4) The Center for Brain Injury Research and Training. (n.d.). Post Concussion Symptom Checklist. Retrieved August 28, 2020, from https://www.education.ne.gov/wp-content/uploads/2017/07/Post-Concussion_Symptom_Checklist.pdf

(5) Mayo Clinic Staff. (2017, July 28). Post-concussion syndrome. Retrieved August 28, 2020, from https://www.mayoclinic.org/diseases-conditions/post-concussion-syndrome/symptoms-causes/syc-20353352

(6) Welch, A., Rapaport, L., Upham, B., & Rauf, D. (2018, March 15). What Complications Can Arise From a Concussion?: Everyday Health. Retrieved August 28, 2020, from https://www.everydayhealth.com/concussion/what-complications-can-arise-from-concussion/

(7) Stamford Health. (2016, February 9). The Role of Vestibular Rehabilitation in the Treatment of Concussion. Retrieved August 28, 2020, from https://www.stamfordhealth.org/healthflash-blog/orthopedic-spine-sports-medicine/vestibular-rehabilitation/

(8) Mucha, A. (2018, March 7). Physical Therapy Guide to Concussion. Retrieved August 28, 2020, from https://www.choosept.com/symptomsconditionsdetail/physical-therapy-guide-to-concussion